DHA Case No. FCP 220397 (Wis. Div. Hearings and Appeals Dec. 29, 2025) (DHS) ↓ Download PDF The Family Care program, through MCOs, must generally provide services that reasonably and effectively address all of the recipient’s long-term needs and outcomes, assist the recipient to be as self-reliant and autonomous as possible, and are cost effective. […] Read more
Tag: 4.2 Benefits
DHA Case No. HMO 220155 (Wis. Div. Hearings and Appeals Dec. 26, 2025) (DHS) ↓ Download PDF Wisconsin Medicaid does not cover experimental services, a determination the Department makes on its own. In this case, the petitioner requested an Occipital Nerve Block, which was denied as experimental. While recognizing that past decisions have considered experimental […] Read more
DHA Case No. CWK 219225 (Wis. Div. Hearings and Appeals Dec. 26, 2025) (DHS) ↓ Download PDF For the Children’s Community Options Program, the right to appeal is limited to the denial of eligibility for services, or a reduction or termination of services. In this case, the petitioner requested coverage of a safety wagon. ALJ […] Read more
DHA Case No. CWK 220287 (Wis. Div. Hearings and Appeals Dec. 16, 2025) (DHS) ↓ Download PDF To be covered by the CLTS program, a service dog must (a) do work or perform tasks for the benefit of a person with a disability, who (b) has a disability that substantially limits his/her ability to perform […] Read more
DHA Case No. FCP 220319 (Wis. Div. Hearings and Appeals Nov. 17, 2025) (DHS) ↓ Download PDF MCOs must develop service plans that reasonably and effectively address the member’s long-term needs and outcomes while also being cost-effective. In this case, My Choice sought to end the petitioner’s placement in an AFH in favor of a […] Read more
DHA Case No. FCP 219522 (Wis. Div. Hearings and Appeals Oct. 28, 2025) (DHS) ↓ Download PDF When an MCO reduces a service, it has the burden to prove that the reduction is appropriate. In this case, Inclusa sought to end a lawn care service because it expected the petitioner’s wife to do the yard […] Read more
DHA Case No. FCP 219433 (Wis. Div. Hearings and Appeals Oct. 16, 2025) (DHS) ↓ Download PDF Family Care MCOs must generally cover services that are needed, but those services must also be cost-effective. In this case, the petitioner was 36 years old, had a corporate guardian, was looking for employment in the community, and […] Read more
DHA Case No. CWA 219315 (Wis. Div. Hearings and Appeals Oct. 9, 2025) (DHS) ↓ Download PDF The IRIS program must generally cover services that are needed and cost-effective. In this case, the petitioner had severe violent behavior that culminated in felony charges after attacking a staff member. After that, only one AFH was both […] Read more
DHA Case No. FCP 219735 (Wis. Div. Hearings and Appeals Nov. 24, 2025) (DHS) ↓ Download PDF The Family Care program must generally provide services that reasonably and effectively address the participant’s long-term needs but are also cost-effective. In this case, the petitioner requested community-based day habilitation services to “remain active and busy in order […] Read more
DHA Case No. FCP 219488 (Wis. Div. Hearings and Appeals Nov. 4, 2025) (DHS) ↓ Download PDF To be covered under Family Care, a service must be cost-effective. In this case, the MCO denied the petitioner’s request for 24/7 supportive home care (SHC), claiming it would be more cost-effective for him to move to a […] Read more
DHA Case No. CWA 218110 (Wis. Div. Hearings and Appeals Sep. 25, 2025) (DHS) ↓ Download PDF IRIS participants may submit one-time expense requests to pay for goods or services, including adaptive aids such as vehicle modifications. In this case, the petitioner requested a wheelchair and hand-controls conversion after her old vehicle, which had been […] Read more
DHA Case No. CWA 218438 (Wis. Div. Hearings and Appeals Sep. 18, 2025) (DHS) ↓ Download PDF Prevocational services may be funded through IRIS, but services in sheltered workshop settings are excluded and the participant must have a goal of community-integrated employment. In this case, the petitioner received prevocational services for 11 years in a […] Read more
DHA Case No. FCP 218531 (Wis. Div. Hearings and Appeals Sep. 4, 2025) (DHS) ↓ Download PDF The Family Care program must generally cover services that reasonably and effectively address the participant’s long-term needs, but those services must also be cost-effective. In this case, the agency denied the petitioner’s request for coverage of a health […] Read more
DHA Case No. FCP 219093 (Wis. Div. Hearings and Appeals Aug. 25, 2025) (DHS) ↓ Download PDF The Family Care program must generally cover services that reasonably and effectively address the participant’s long-term needs, but those services must also be cost-effective. In this case, the petitioner’s home-delivered meals ended because his plan already included Supportive […] Read more
DHA Case No. CWA 218425 (Wis. Div. Hearings and Appeals Aug. 11, 2025) (DHS) ↓ Download PDF Prevocational services may be funded through IRIS, but the participant must have a goal of community-integrated employment. In this case, the petitioner received prevocational services for three years as part of his IRIS budget (and it appears he […] Read more